Subclavian artery to external carotid artery bypass with saphenous vein graft in the treatment of common carotid artery stenosis

A case of TIAs due to proximal common carotid artery stenosis which was successfully treated with autogenous saphenous vein graft between the subclavian artery and the external carotid artery is presented. A 57-year-old, right handed female was admitted to our hospital for the treatment of left common carotid artery stenosis which was pointed out at a local hospital. She had a 7-years' history of repeated transient right hemiparesis and/or left amaurosis fugax. No neurological deficit was revealed on admission. Angiography showed an 80% irregular stenosis of the left common carotid artery at its origin, hypoplastic A1-portion of the left anterior cerebral artery and hypoplasia of the left posterior communicating artery. No other stenotic lesions were disclosed in a four-vessel study. Several kinds of surgical procedures have been reported for the treatment of common carotid stenotic lesion, in accordance with the site and extension of the lesion and hemodynamic factors. To maintain a sufficient blood flow of the left internal carotid artery, we considered four different operative methods such as (1) endarterectomy of the common carotid artery, (2) subclavian to common carotid artery bypass, (3) subclavian to external carotid artery bypass and (4) subclavian to middle cerebral artery bypass. The first two operative procedures force to clamp the common carotid artery which was the only one feeding artery of the left middle cerebral artery because of poor cross flow in this case. These procedures were thought highly possibly to give rise to cerebral infarction on the left side. The fourth method needs a long graft which has higher risk of bypass occlusion.(ABSTRACT TRUNCATED AT 250 WORDS)     

Left carotid steal. A new observation.

A patient had an occlusion of the left subclavian artery just proximal to the takeoff of a previously placed subclavian-carotid graft. This caused reversal of flow in the graft and a symptomatic steal of blood via to the intracranial arteries. An axilloaxillary graft restored forward flow. In a second patient, a steal occurred from the right carotid and vertebral systems into the distal carotid system of the left side that has been isolated by a proximal carotide artery occlusion from arteriosclerosis. A saphenous vein, used as a bypass from the subclavian to the carotid artery, restored normal flow. Thus, the carotide system may be the low-pressure area responsible for the steal, although this is rarer than the subclavian.     

Subclavian artery to internal carotid artery bypass with saphenous vein graft in the treatment of bilateral common carotid artery occlusion; a case report]

A case of left common carotid artery occlusion, which was treated by a saphenous vein graft, is reported. A 49-year-old right handed male was admitted to the hospital because of right hemiparesis and aphasia. These symptoms disappeared spontaneously two weeks after admission. However, visual acuity remained impaired on the left side due to occlusion of the central retinal artery. Angiography revealed complete occlusion of the common carotid arteries as well as patency of the internal carotid arteries on both sides. PET and 123I-IMP-SPECT studies showed hypoperfusion in the left cerebral hemisphere. To restore the blood flow as well as to remove the source of the emboli, endarterectomy was performed on the left internal carotid artery. This was followed by a saphenous vein graft between the left subclavian and the internal carotid artery. Postoperative angiography revealed patency of the bypass, and a SPECT study revealed increased blood flow in the left cerebral hemisphere. The patient has remained in stable condition during the following 30 months with no neurological problems. We conclude that in the treatment of complete occlusion of the common carotid artery and subsequent cerebral hypoperfusion, a bypass graft between the internal carotid and the subclavian artery is quite effective, and that the site of the bypass graft should carefully be sought for by using preoperative angiographic studies.     

Use of axillary artery to maintain cerebral perfusion in a patient requiring reconstruction of the brachiocephalic trunk and coronary arteries: technical note

Our patient had 80% stenosis of the brachiocephalic artery and total occlusion of the left carotid and left subclavian arteries. Ascending aorta to brachiocephalic artery bypass grafting was performed, with a 10 mm Dacron graft. The right axillary artery was cannulated, and during construction of the distal anastomosis cerebral blood flow was from the right axillary artery. We believe this technique may be beneficial in surgery on an artery in which cerebral blood flow depends exclusively.     

Ipsilateral subclavian to external carotid and STA-MCA bypasses for retinal ischemia

The surgical treatment of a patient with retinal ischemia in the left eye and occlusion of the left common and internal carotid and right internal carotid arteries is presented. After demonstration of filling of the left external carotid artery from vertebral collaterals, as saphenous vein graft from the left subclavian to the left external carotid artery was performed prior to a left superficial temporal artery to middle cerebral artery bypass. This case demonstrates the feasibility of revascularization in the presence of occlusion of the ipsilateral common and internal carotid arteries.     

杂交技术治疗主动脉弓降部病变的临床研究

目的:探讨杂交技术治疗主动脉弓降部病变的效果。方法:采用杂交技术(解剖外旁路联合血管腔内修复术)手术治疗10例患者,包括累及主动脉弓部分支的B型主动脉夹层4例和主动脉弓降部真性动脉瘤6例。其中左颈总动脉至左椎动脉旁路1例,右颈总动脉至左颈总动脉旁路5例,右颈总动脉至左颈总动脉及左颈总动脉至左锁骨下动脉旁路1例和升主动脉至无名动脉及左颈总动脉旁路3例。均经股动脉入路植入覆膜支架。结果:10例患者均获得技术成功,1例发生少量I型内漏,未处理。术后1例因脑梗塞伴肺炎、肾功能衰竭不治自动出院;其余9例均痊愈出院。9例随访时间3～33个月,均恢复正常生活,术后3个月CTA示:覆膜支架无移位,1例内漏已消失,无新的内漏发生,夹层假腔或动脉瘤腔内已有血栓形成,远端夹层假腔无明显扩大,旁路人工血管通畅。结论:杂交手术避免体外循环损害,减轻外科手术创伤,提高了治疗效果,是治疗累及分支的主动脉弓降部病变的重要方法。     

Combined open and endovascular treatment of a right subclavian artery aneurysm: a case report

A 69-year-old man with previous ascending aortic repair combined with valve replacement for an ascending aortic aneurysm presented with a type 2 thoracoabdominal aneurysm and a 4.4-cm aneurysm of the right subclavian artery. Because of the anatomic location of the aneurysm and his previous operation, an innominate to carotid artery stent graft and a carotid-subclavian bypass and vertebral artery bypass were performed. Postoperative computed tomographic angiography confirmed good flow in the right carotid and vertebral artery, and the patient recovered without complication.     

Techniques for preserving vertebral artery perfusion during thoracic aortic stent grafting requiring aortic arch landing.

Thoracic endografting offers many advantages over open repair. However, delivery of the device can be difficult and may necessitate adjunctive procedures. We describe our techniques for preserving perfusion to the left subclavian artery despite endograft coverage to obtain a proximal seal zone. We reviewed our experience with the Talent thoracic stent graft (Medtronic, Santa Rosa, CA). From 1999 to 2003, 49 patients received this device (29 men, 20 women). Seventeen patients required adjunctive procedures to facilitate proximal graft placement. We performed left subclavian-to-left common carotid artery transposition (6), left common carotid-to-left subclavian artery bypass with ligation proximal to the vertebral artery (7), and left common carotid-to-left subclavian artery bypass with proximal coil embolization (4). Patients who had anatomy unfavorable to transposition or bypass with proximal ligation (large aneurysms or proximal vertebral artery origin) were treated with coil embolization of the proximal left subclavian artery in order to prevent subsequent type II endoleaks. Technical success rate of the carotid subclavian bypass was 100%. Patient follow-up ranged from 3 to 48 months with a mean of 12 months. Six patients had follow-up <6 months owing to recent graft placement. Primary patency was 100%. No neurologic events occurred during the procedure or upon follow-up. One patient had a transient chyle leak that spontaneously resolved in 24 hours. Another patient had a phrenic nerve paresis that resolved after 3 weeks. We believe that it is important to maintain patency of the vertebral artery specifically when a patent right vertebral system and an intact basilar artery is not demonstrated. Furthermore, we describe a novel technique of coil embolization of the proximal left subclavian artery in conjunction with left common carotid-to-left subclavian artery bypass. This circumvents the need for potentially hazardous mediastinal dissection and ligation of the proximal left subclavian artery in cases of large proximal aneurysms or unfavorable vertebral artery anatomy.     

A simple and safe operation method for brachiocephalic artery aneurysms

A 64-year-old man was referred to our hospital due to dyspnea and fever. The chest computed tomogram revealed a 60-mm aneurysm of the brachiocephalic artery with mural thrombus. The aneurysm of the brachiocephalic artery and the right subclavian artery were exposed through only median sternotomy. Cardiopulmonary bypass with synchronized pulsatile perfusion was established with the ascending aorta and bi-caval cannulation. A mean arterial pressure was kept at between 60 and 70 mmHg with the unloaded beating heart. Mild hypothermia was induced (blood temperature 27 degrees C, nasopharyngeal temperature 32 degrees C). The brachiocephalic artery, right carotid artery, and right subclavian artery were clamped when nasopharyngeal temperature was 32 degrees C after decreasing blood temperature to 27 degrees C. After opening the aneurysm, the mural thrombus and calcified aneurysmal wall were removed. First, an ascending aorta to the right common carotid artery bypass was performed using a 16-8 mm Y- prosthetic graft with side-clamp forceps. After the anastomosis, the right side cerebral perfusion was restarted and the patient was rewarmed. Then the right subclavian artery was anastomosed in an end-to-end fashion. The duration of the right side cerebral circulatory arrest was 30 minutes. The patient left hospital seven days after the operation.     

Aortic arch branches are no longer a blind zone for transesophageal echocardiography: a new eye for aortic surgeons

OBJECTIVES: Branch arteries of the aortic arch have been a blind zone for transesophageal echocardiography. Information regarding blood flow, which is important in both planned and emergency operations on the aorta, has therefore been limited. We have established a technique for visualizing these arteries in nearly all cases. METHODS: In 25 consecutive patients requiring either planned or emergency operations on the aorta, the branch arteries were visualized whenever cerebral malperfusion was suspected. Lateral flexion of the probe tip was used when the trachea interfered with visualization of the arteries. RESULTS: The left subclavian, left and right common carotid, right subclavian, innominate, and left and right vertebral arteries were visualized in 96% (24/25), 92% (23/25), 96% (24/25), 100% (25/25), 84% (21/25), 92% (22/24), and 88% (21/24), respectively. The origin of the innominate artery was visualized in 36% (9/25). In some cases, dissection extended into branch arteries during surgery or during conservative therapy. When the subclavian artery was clamped, retrograde flow was detected in the vertebral artery (steal flow). The cannula for selective cerebral perfusion occasionally was entered into the right common carotid or subclavian artery and obstructed the other branch with a balloon. CONCLUSIONS: The branch arteries of the aortic arch, including the vertebral artery, are no longer a blind zone for transesophageal echocardiography. The information obtained with our new transesophageal echocardiography technique is helpful for diagnosis, monitoring, and decision making during aortic surgery and in critical care medicine. Visualizing these vessels is worth the effort.     

Total arch replacement through a mediansternotomy for an aortic arch aneurysm with an aberrant right subclavian artery

The patient was a 77-year-old man. In 2004, he developed thrombosed aortic dissection extending from the distal aortic arch to the renal artery bifurcation. He was discharged after his condition improved with conservative treatment. He was followed up as an outpatient because there was an aneurysm, which measured 50 mm in diameter, at the aortic arch. Thereafter the aneurysm gradually enlarged. In May 2009, computed tomography (CT) showed that the aneurysm had increased to 10 cm in diameter and the patient began to have back pain. Thus, surgery was planned. CT revealed that the right subclavian artery originated distal to the left subclavian artery and coursed posterior to the esophagus and trachea. Surgery was performed using median sternotomy. Arch replacement and right subclavian artery reconstruction were performed under hypothermic circulatory arrest with selective cerebral perfusion. The right subclavian artery was controlled at the right border of the trachea, and cerebral perfusion was performed at this site. An end-to-side anastomosis to the reconstructed right common carotid artery was performed by an anterior tracheal approach. The patient had no cerebral complications and his postoperative course was uneventful.     

Bypass surgery for occluded internal carotid artery revascularized by vasa vasorum--case report

A 47-year-old woman presented with two transient ischemic attacks due to occlusion of the left internal carotid artery. The affected artery was revascularized by vasa vasorum. Angiography showed occlusion of the left common carotid artery including the origin of the internal carotid artery. The distal internal carotid artery was revascularized by vasa vasorum at the level of the second cervical vertebral body. Left subclavian artery-internal carotid artery bypass surgery using a saphenous vein graft was performed successfully, during which the narrowed but patent lumen of the internal carotid artery was confirmed. Follow-up angiography showed enlargement of the left internal carotid artery distal to the patent bypass. Reconstructive bypass surgery is a possible treatment for patients with occluded internal carotid artery revascularized by vasa vasorum. Angiographic detection of the lumen of the internal carotid artery is important for surgical consideration.     

A successful surgical treatment of ascending aortic aneurysm, left common carotid artery aneurysm and left subclavian artery obstruction due to aortitis syndrome in active phase]

A 24-year-old female was admitted complaining of coldness of left upper extremity and pulsating tumor of the neck. She was diagnosed as ascending aortic aneurysm, left common carotid artery aneurysm and left subclavian artery obstruction due to aortitis syndrome on examinations. Although steroid treatment appeared to be effective in controlling inflammatory reaction, the left common carotid artery aneurysm increased in size and severe neck pain started. The risk of rupture was feared, and surgical intervention was carried out in spite of aortitis in active phase. The patient underwent surgery where aneurysmectomy and graft replacement for ascending aortic aneurysm, aneurysmectomy and graft replacement using autogenous saphenous vein for left common carotid artery aneurysm and bypass grafting for left subclavian artery obstruction were performed. The histology of resected specimens of aortic wall showed active aortitis. The postoperative course was uneventful and the patient was discharged on steroid.     

Vertebral artery embolic protection via ipsilateral brachial approach during left subclavian artery angioplasty and stenting--a case report

The purpose of this report is to explore angioplasty and stenting with cerebral embolic protection as a salvage procedure for a compromised carotid-subclavian bypass in the presence of antegrade vertebral artery flow. A 76-year-old woman with a carotid-subclavian bypass presented with graft infection. Failure of medical therapy to treat the infection prompted surgical removal of the graft. The native subclavian artery was still patent, but a severe complex proximal stenosis was present with antegrade flow into the left vertebral artery. Angioplasty and stenting of the subclavian artery was performed with cerebral protection achieved by positioning a FilterWire EX in the left vertebral artery via the left brachial artery approach. Deployment of a filter device in the vertebral artery via the brachial or radial approach can provide embolic protection without interfering with the subclavian artery stenting. The successful treatment of the subclavian artery enabled the complete removal of the infected graft without need for major vascular reconstruction.     

Proximal ligation of the parent artery for symptomatic tandem stenosis of the extradural internal carotid artery: a case report

A 72-year-old man suffered blindness due to right central retinal artery occlusion. Cerebral angiography revealed tandem stenosis in the cervical, petrosal and cavernous portions of the right internal carotid artery (ICA). Blood flow from the vertebrobasilar artery via the right posterior communicating artery mainly perfused the right cerebral hemisphere. In addition, significant stenosis was observed in the left cervical carotid artery and the origin of the left vertebral artety. First, the patient underwent left carotid endarterectomy and vertebral artery to subclavian artery transposition. Two months later, ligation of the right ICA at its origin was performed. Postoperative course was uneventful and the patient has not experienced further ischemic events. We suggest that proximal ligation of the parent artery is a useful procedure for medically-refractory extradural ICA stenosis when surgical direct revascularization and percutaneous transluminal angioplasty cannot be performed.     

Congenital right subclavian artery aneurysm: a case report

Aneurysms of the subclavian artery are unusual. The most common causes are atherosclerosis and trauma. We report one case of an elongated and tortuous right subclavian artery with an aneurysm involving the origin of the right vertebral artery. The patient underwent resection of the lesion with an end-to-end anastomosis of the subclavian artery and implantation of the right vertebral artery into the right common carotid artery. Results were consistent with a rare congenital subclavian aneurysm.     

Subclavian-external carotid bypass for symptomatic severe cerebral ischemia from common and internal carotid artery occlusion

Occlusion of the common and internal carotid arteries in a patient with symptomatic severe cerebral ischemia, with or without contralateral carotid disease, portends a poor prognosis. The present study has described our experience with subclavian and external carotid artery revascularization for symptomatic severe cerebral ischemia from common and internal carotid artery occlusion. Nine patients (five men and four women) with a mean age of 62 (range 41 to 82 years) were diagnosed as having symptomatic severe cerebral ischemia. All patients had ipsilateral hemispheric symptoms, seven had amaurosis fugax, and two had associated syncope. Four patients (three men and one woman) were hypertensive, four (two men and two women) had diabetes, eight smoked, and all had a history of coronary artery disease. All of the patients had noninvasive laboratory studies and preoperative angiography, and three had postoperative angiography. Five patients were successfully revascularized to a patent external carotid artery despite nonvisualization by angiography. Six patients had unilateral and three bilateral occlusion of the common and internal carotid arteries appropriate to their symptoms. Using regional anesthesia, four patients underwent a subclavian-external carotid bypass with polytetrafluoroethylene; saphenous vein was used in five; and three had concomitant axilloaxillary bypass grafting with polytetrafluoroethylene. Neurologic improvement (that is, no subsequent deficit and no progression of symptoms) was noted in all nine patients with a follow-up of 4 to 28 months (mean 11.2 months). Two patients died from myocardial infarction 4 and 7 months after operation. Subclavian-external carotid artery bypass is a safe addition to the options for the treatment of symptomatic severe cerebral ischemia with occlusion of the common and internal carotid arteries, visualization of a superior thyroid collateral vessel on the recipient end, and nonvisualization of the external carotid artery.     

Coronary subclavian steal syndrome; report of a case

A 64-year-old man was admitted to our hospital with chief complaint of chest discomfort. He received coronary artery bypass grafting utilizing the in situ left internal thoracic artery 10 years ago. Coronary and left subclavian artery angiogram revealed coronary subclavian steal syndrome and 90% stenosis in the proximal left subclavin artery. Ultrasonography of neck vessels demonstrated 75% stenosis in the bifurcation of left carotid artery. We performed axilloaxillary artery bypass grafting to avoid brain ischemia. Myocardial thallium scintigraphy on dipyridamole testing after axilloaxillary artery bypass grafting could not detect myocardial ischemia. Axilloaxillary artery bypass grafting was effective for coronary subclavian steal syndrome.     

Treatment of subclavian artery stenosis: A case series

IntroductionIn this case series, different modalities of treatment for patients with ischaemic symptoms of subclavian stenosis are described, including the different operative strategies that can be adopted in more challenging cases. This is the first case series describing these four management options.PresentationCase 1: A seventy-one year-old female presented with acute on chronic ischaemia of her left arm following a fall and developed dry gangrene of her left thumb. This was initially managed with a heparin infusion followed by stenting of the subclavian artery which relieved her symptoms. Case 2: A fifty-nine year-old male presented with chronic ischemia of the left arm secondary to an occlusion of the left subclavian artery. This was managed by transposition of the left subclavian artery onto the left common carotid artery. Case 3: A sixty-four year-old female presented with left subclavian steal syndrome secondary to subclavian artery stenosis. She underwent carotid subclavian artery bypass. Case 4: A fifty-six year-old female presented with acute left upper limb ischaemia secondary to acutely thrombosed subclavian artery on a CT-angiography. She underwent a carotid to axillary bypass.Discussion and conclusionThis case series demonstrates the treatment options available to vascular surgeons when managing symptomatic subclavian artery disease. Symptomatic subclavian artery occlusive disease should be treated with endovascular stenting and angioplasty as first line management. If it is not successful then open surgery should be considered. Bypassing the carotid to the subclavian or to the axillary artery are both good treatment modalities.